General Med - A wrap up (part 1)

Well I apologize that I haven't written more for this general med term. I meant to. The term was very hectic and when I finally got a moment to think, I just didn't want to write.

The tone of the rotation dramatically changed toward the end. It went from being part of the med team, being part of rounds (generally experiencing life as a junior doc on general med) to one of, looking for long and short cases, trying to fit in study where you could around all the scheduled tutes and generally in exam prep mode. It was a necessary shift in focus (if we would hope to pass the exams) but after that the registrars/consultants seemed less inclined to involve you in the care of the patients.

The assessment (like all so far this year) consisted of 4 parts worth 25% of which one part was the consultant's mark. On this rotation the other 75% was from 2 short cases and 1 long case done on the last day.

The Long case was a patient on the ward. You were told the patient name/bed number and went straight to that patient. You had an hour alone with the patient (mostly uninterrupted, there is always morning or afternoon tea or the tv hirer or some physio/nurse interrupting which you have to quickly deal with) to take a detailed history, work out active problems (noting inactive ones) and taking a detailed social history intergrating all with a physical exam. You then have ten minutes to organise your thoughts then you have to formally present the problem to 2 examiners (one being the specialist looking after that patients presenting/main issue). You are then asked to list problems, investigations, and might have to interpret an ECG, blood gas analysis or chest xray. You are pimped for about 10mins by the two examiners. An example might be... Mr S is a 60 yr old man who presented with increasing SOB and productive cough of two weeks duration. This is on a backgroud of Chronic airway disease, Ischaemic Heart disease, Hypercholesterolaemia, Hypertention and poorly controlled Diabetes Mellitus. He has a cumulated 90 pack year smoking history, still smokes and has been on oral prednisolone (30mg) for 9 months now for frequent exacerbations of his COPD".
The problem list might constist of

1. Diagnostic and Management problem of Increasing SOB (DDX: Exacerbation of COPD or pneumonia, Lung cancer, Heart failure etc) - Including tapering steroids if possible (risk of osteoporosis, high glucose levels)
   
2. Management of his IHD (Incl. Cholesterol, HTN etc)
3. Management of His Diabetes Mellitus
4. Assist lifestyle modification (Stress reduction, wt loss, quiting smoking)
5. Assist with rehab to work or short-term financial aid (welfare etc)

The two short cases immediately follow where the examiners then take you to patients (often brought in especially for the exam) with nonurgent, but often interesting pathology. You have 10mins per patient to examine ("Mr x presents with increasing shortness of breath on exertion, please examine his cardiovascular system") Short cases took 10 minutes. Obviously, not all cases are cardiorespiratory in nature, they are very common however and these were the first I thought of as typical examples.